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1. Product:
Product

Quantity

Billing Frequency

Fall Detection

Sentinel

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Billing Frequency

Shipping Method
12 Months

Monthly
FedEx Priority (generally received in 2 business days)$15.95

Next Business Day$59.95
Total:

Activation Fee: $0.00 Total with shipping and tax: $0.00
2. Credit Card Info:
- * Card Type:
- * Card Number:
- * Exp. Month:
- Exp. Year:
- * CID:
3. Billing and Shipping Info:
- * First Name:
- * Last Name:
- * Phone:
- * Email:
- * Address:
- Address 2:
- * City:
- * State:
- * Zip:
Shipping different from billing
- * First Name:
- * Last Name:
- * Phone:
- * Address:
- Address 2:
- * City:
- * State:
- * Zip:
- * Email:
4. User/Member:
- * User First Name:
- * User Last Name:
- * Primary Phone:
- * Primary Phone Type:
- * Address:
- Address 2:
- * City:
- * State:
- * Zip:
5. Who should be contacted first in case of an emergency?

Special Notes (anything our Emergency Monitoring Center should know):

If you would like to add additional responders or set up notifications, please call 1-866-802-3676 when your system arrives.
6. Personal or Company Emergency Contacts:
- * Name:
- * Relationship to user:
- * Phone:
- * Type of Phone:
Thanks for your order!

Total with shipping and tax: $0.00